Healthcare Provider Details

I. General information

NPI: 1114310018
Provider Name (Legal Business Name): LOGAN P CHAMBERLAIN DC, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2015
Last Update Date: 01/15/2020
Certification Date: 01/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 W ARCH HAVEN AVE STE C
BLOOMINGTON IN
47403-2078
US

IV. Provider business mailing address

6296 W. BOGGSTOWN RD.
BOGGSTOWN IN
46110
US

V. Phone/Fax

Practice location:
  • Phone: 812-333-7447
  • Fax: 812-333-7442
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08003143A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: